Spontaneous and procedural plaque embolisation in native coronary arteries: pathophysiology, diagnosis, and prevention

Giovanni Luigi De Maria, Niket Patel, George Kassimis, Adrian P Banning, Giovanni Luigi De Maria, Niket Patel, George Kassimis, Adrian P Banning

Abstract

The detachment of atherothrombotic material from the atherosclerotic coronary plaque and downstream embolisation is an underrecognized phenomenon and it causes different degrees of impairment of the coronary microcirculation. During treatment of obstructive atherosclerotic plaque by percutaneous coronary intervention (PCI) distal embolisation (DE) is considered to be inevitable and it is associated with potential clinical and prognostic implications. This review aims to assess the main aspects of both spontaneous and procedural DE, analyze their different pathophysiology, provide specific insights on the main diagnostic tools for their identification, and finally focus on the main strategies for their treatment and prevention.

Figures

Figure 1
Figure 1
No reflow versus normal myocardial perfusion after revascularization.
Figure 2
Figure 2
Mechanisms and consequences of “spontaneous” and “procedural” distal embolisation in stable coronary artery disease and in acute coronary syndrome. In spontaneous distal embolisation, occurring only in ACS patients, dislodgement of atherothrombotic debris contributes to enlargement of the area of myocardial injury and microvascular obstruction consequent to epicardial coronary occlusion. This damage is further increased by debris shower during revascularization procedure (procedural distal embolisation). In stable coronary artery disease only procedural distal embolisation occurs, causing patchy microinfarcts.
Figure 3
Figure 3
Mechanisms leading to left ventricular impairment after distal embolisation. Inflammatory response and shear stress at the interface between embolised and non embolised myocardium trigger the cytokines cascade which leads to myofibrillar proteins oxidation and reduced calcium responsiveness, underlying left ventricular dysfunction after distal embolization.
Figure 4
Figure 4
Prevention and treatment of spontaneous and procedural distal embolisation. Main mechanical and pharmacological options to treat and prevent distal embolisation in native vessels are reported according to their contribution in dealing with both spontaneous and procedural distal embolisation. Notably since spontaneous distal embolisation has already occurred or is ongoing at admission, pharmacological strategies are adopted with an only “therapeutic” intention in order to reduce the impact of embolised debris on myocardium. On the contrary the same drugs have a double role, preventive and therapeutic, in case of procedural distal embolisation.

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Source: PubMed

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